Wednesday, November 28, 2007

Rapid response teams in perspective

I don’t have anything against rapid response teams (RRTs) although I’ve long suspected that they are promoted way beyond what the evidence supports. Yesterday saw some thoughtful blogging on the subject. Bob Wachter, though somewhat of a skeptic on RRTs, notes that the appeal is undeniable:

Don’t get me wrong. The concept of a Rapid Response Team is attractive. It isn’t hard to find patients who die in hospitals or require emergent transfer to the ICU in whom evidence of deterioration was present for hours – sometimes days – before the crash.

Indeed. Wachter goes on to mention Joint Commission’s 2008 National Patient Safety Goals number 16 of which states:

The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

This is rather vague, to Joint Commission’s credit, in that it allows individual institutions to fashion a method that meets their individual needs in this area. Wachter’s interpretation is that each hospital have a system in place to identify deteriorating patients and intervene. Such a system may or may not take the form of a RRT in the usual sense.

California Medicine Man, acknowledging the scarcity of data in support of RRTs, notes that some of the things such teams can do, such as administration of fluid boluses and respiratory treatments, just make sense. Moreover, the nurses feel more confident when such teams are available.

If RRTs are such a good idea who cares if they aren’t “evidence based?” If a RRT suits your hospital’s needs maybe you don’t need a study to justify it. It’s all well and good up to a point. It becomes problematic when unsupported claims are made (“we’re saving lives”) or rigid mandates are promulgated. That’s when I’ll say “show me the evidence.”

So, what does the evidence say? I’ve previously noted the lack of evidence in support of RRTs. Last month I blogged about a more recent systematic review which again failed to support RRTs. Wachter cited some more recent studies. Just out in JAMA is a paper showing a reduction in mortality associated with a RRT in a children’s hospital. Can such results be extrapolated to adult hospital medicine? Probably not. Things move faster in pediatrics. Compared to adult medicine everything in pediatrics is stat.

Perhaps the most interesting study Wachter mentioned was this one which demonstrated a remarkable reduction in mortality. In fact, the authors estimated that by the end of the study period the NNT to save one life was 3! Astounding! But take a closer look at what they really did. It wasn’t a RRT as we generally think of it. It was really early goal directed therapy.

So it all depends on what we really mean when we speak of RRTs. I suspect for many hospitals RRTs meet an important need. For others they may be no more than a promotional gimmick, an exercise in symbol over substance.